A novel whole blood capillary technic for measuring the prothrombin time

The prothrombin time (PT) is frequently performed to monitor anticoagulant therapy. Although relatively simple to perform, it requires venipuncture and laboratory resources for sample handling and analysis. A recently developed capillary whole blood device that uses fingerstick samples was evaluated. Paired capillary whole blood and reference plasma PTs were performed in 858 samples from 732 subjects. The PT for normal volunteers (n = 193) was 11.8 +/- 0.9 seconds with the use of the new instrument and 12.1 +/- 0.5 seconds with the use of the reference method. In samples from 539 patients receiving anticoagulants, the correlation coefficient between the two methods was 0.96. Venous whole blood without anticoagulant and capillary whole blood gave equivalent results, which suggests that the fingersticks do not effect the quality of the specimen. Variation in hematocrit between 23.4% (0.34) and 53.8% (0.538) did not alter the performance of the instrument. The new instrument is easy to use and may allow testing by nonlaboratory personnel and patients. It obviates the need for venipuncture, provides immediate results, and appears to be comparable in accuracy to current reference methods.     

Evaluation of Optium Xceed (Abbott) and One Touch Ultra (Lifescan) glucose meters

In order to build a continuous quality improvement approach for control of glucose meters in clinical divisions at Necker-Enfants Malades hospital, the analytical performances (precision and accuracy) of 2 glucose meters have been evaluated in our laboratory according to SFBC recommendations. Fifty-six heparinized whole blood specimens from patients and thirty-nine from healthy volunteers were analyzed on each of the two meters and compared to plasma glucose measurement on the Roche Hitachi 917 system. The correlation coefficient was 0.938 for Optium Xceed and 0.911 for One Touch Ultra. However, 14.7% and 18.9% of the results (n = 95) for respectively Optium Xceed and One Touch Ultra were discordant, i.e. higher than a 20% difference compared to reference blood glucose concentrations. Inaccuracy was more important for low glucose concentrations (< 5 mmol/L; 12/14 discrepant samples for Optium Xceed and 16/19 for One Touch Ultra). This data suggests a lack of accuracy, particularly for low glucose concentrations. Capillary blood glucose concentrations must therefore be interpreted with caution concerning the diagnosis of hypoglycemia and treatment of unstable patients. Moreover, quality control of glucose meters (blood glucose determinations concurrently at bedside and in the laboratory) is difficult to perform. It also raises questions about the responsibility of "point-of-care testing", an area still subject to discussion.     

Accuracy of roche accu-chek inform whole blood capillary, arterial, and venous glucose values in patients receiving intensive intravenous insulin therapy after cardiac surgery

Intravenous insulin protocols are increasingly common in the intensive care unit to maintain normoglycemia. Little is known about the accuracy of point-of-care glucometers for measuring glucose in this patient population or the impact of sample source (capillary, arterial, or venous whole blood) on the accuracy of glucometer results. We compared capillary, arterial, and venous whole blood glucose values with laboratory plasma glucose values in 20 patients after cardiac surgery. All 4 samples (capillary, arterial, and venous whole blood and laboratory plasma glucose) were analyzed hourly for the first 5 hours during intravenous insulin therapy in the intensive care unit. There were no significant differences between median capillary whole blood (149 mg/dL [8.3 mmol/L]) and laboratory plasma (151 mg/dL [8.4 mmol/L]) glucose levels. The median arterial (161 mg/dL [8.9 mmol/L]) and venous (162 mg/dL [9.0 mmol/L]) whole blood glucose levels were significantly higher than the median laboratory plasma glucose level. Capillary whole blood glucose levels correlate most closely with laboratory plasma glucose levels in patients receiving intensive intravenous insulin therapy after cardiac surgery.     

Distinction between normal and renal cell carcinoma kidney cortical biopsy samples using pattern recognition of (1)H magic angle spinning (MAS) NMR spectra

The technique of magic angle spinning (MAS) high resolution (1)H NMR spectroscopy applied to intact tissues provides excellent peak resolution and thus much biochemical information. The use of computer-based pattern recognition techniques to classify human renal cortex tissue samples as normal or tumour based on their (1)H MAS NMR spectra has been investigated. In this preliminary study of 22 paired control and tumour samples, exploratory data analysis using principal components based on NMR spectral intensities showed clear separation of the two classes. Furthermore, using the supervised method of linear discriminant analysis, based on individual data point intensities or on integrated spectral regions, it was possible to distinguish between the normal and tumour kidney cortex tissue with 100% accuracy, including a single example of a metastatic tumour from a primary lung carcinoma. A tumour sample from the collecting duct of the kidney showed a different NMR spectral profile, and pattern recognition indicated that this sample did not classify with the cortical tumours.     

Evaluation of artificial pancreas technology for continuous blood glucose monitoring in dogs

Artificial pancreas technology, involving “closed-loop??controls with real-time blood glucose monitoring, has been increasing in reliability as its potential for clinical use and application grows. One such device, based on this technology, is the STG-22 (Nikkiso Co., Ltd., Tokyo, Japan) artificial pancreas apparatus. In order to assess the reliability and accuracy of the device for measuring blood glucose, it is important to compare its readings to those obtained using a ‘gold standard??method, such as the hexokinase method. Therefore, in the present study, canine blood [glucose] measurements using the STG-22 were compared to those obtained using a previously established commercial reagent, Quickauto-Neo GLU-HK. Furthermore, two different sample types (whole blood versus plasma constituent) were compared to determine which sample type results in more accurate and optimal readings with the STG-22. Given that the STG-22 was not primarily designed for canine blood samples, results for canine blood samples were not accurate. Measurements performed by the STG-22 with whole blood were significantly lower than reference [glucose] counterparts. Alternatively, an opposite trend was observed with plasma measurements that were significantly higher. A conversion format using the following formula, Hexokinase [glucose]?=?STG-22 [glucose]?×?1.407?+?1.532, was observed with canine samples in our study.     

The use of Fourier-transform infrared spectroscopy for the quantitative determination of glucose concentration in whole blood

Fourier-transform infrared transmission spectroscopy has been used for the determination of glucose concentration in whole blood samples from 28 patients. A 4-vector partial least-squares calibration model, using the spectral range 950-1200 cm(-1), yielded a standard-error-of-prediction of 0.59 mM for an independent test set. For blood samples from a single patient, we found that the glucose concentration was proportional to the difference between the values of the second derivative spectrum at 1082 cm(-1) and 1093 cm(-1). This indicates that spectroscopy at these two specific wavenumbers alone could be used to determine the glucose concentration in blood plasma samples from a single patient, with a prediction error of 0.95 mM.     

近红外光谱无创血糖检测模拟样品的试验研究

目的：采用蛋白质混合液作为模拟样品、对近红外光谱血糖测量中的测量方法和波长选择等基础问题进行了研究。方法：在1400nm～1800nm和2000nm～2500nm的波段，模拟样品中60个作为校正集样品，使用Nexus-870傅立叶干涉红外光谱仪生成近红外漫反射光谱，采用平滑、基线和微分校正处理，用偏最小二乘法（PLS）建立了葡萄糖测定的校正模型。20个作为测试集样品．用于检验模型的预测能力。结果：在2000nm～2500nm波段内，经过平滑、基线和微分处理的校正模型相关系数达到0．998，预测集样本的标准偏差（RMSEP）达到了0．045。结论：平滑和基线校正配合微分处理可以有效的消除各个方面的噪声，如电噪声、杂散光等，优化光谱信号，提高模型的预测能力。本文研究结果为近红外光谱血糖测量的深入研究提供了理论和实践上的指导。     

LTR real‐time PCR for HIV‐1 DNA quantitation in blood cells for early diagnosis in infants born to seropositive mothers treated in HAART area (ANRS CO 01)

HIV‐1 diagnosis in babies born to seropositive mothers is one of the challenges of HIV epidemics in children. A simple, rapid protocol was developed for quantifying HIV‐1 DNA in whole blood samples and was used in the ANRS French pediatric cohort in conditions of prevention of mother‐to‐child transmission. A quantitative HIV‐1 DNA protocol (LTR real‐time PCR) requiring small blood volumes was developed. First, analytical reproducibility was evaluated on 172 samples. Results obtained on blood cell pellets and Ficoll‐Hypaque separated mononuclear cells were compared in 48 adult HIV‐1 samples. Second, the protocol was applied to HIV‐1 diagnosis in infants in parallel with plasma HIV‐RNA quantitation. This prospective study was performed in children born between May 2005 and April 2007 included in the ANRS cohort. The assay showed good reproducibility. The 95% detection cut‐off value was 6 copies/PCR, that is, 40 copies/10⁶ leukocytes. HIV‐DNA levels in whole blood were highly correlated with those obtained after Ficoll‐Hypaque separation (r = 0.900, P < 0.0001). A total of 3,002 specimens from 1,135 infants were tested. The specificity of HIV‐DNA and HIV‐RNA assays was 100%. HIV‐1 infection was diagnosed in nine infants before age 60 days. HIV‐DNA levels were low, underlining the need for sensitive assays when highly active antiretroviral therapy (HAART) has been given. The performances of this HIV‐DNA assay showed that it is adapted to early diagnosis in children. The results were equivalent to those of HIV‐RNA assay. HIV‐DNA may be used even in masked primary infection in newborns whose mothers have received HAART. J. Med. Virol. 81:217–223, 2009. © 2008 Wiley‐Liss, Inc.     

Direct measurements of blood glucose concentration in the presence of saccharide interferences using slope and bias orthogonal signal correction and Fourier transform near-infrared spectroscopy

Saccharide interferences such as Dextran, Galactose, etc. have a great potential to interfere with near infrared (NIR) glucose analysis since they have a similar spectroscopic fingerprint and are present physiologically at large relative concentrations. These can lead to grossly inappropriate interpretation of patient glucose levels and resultant treatment in critical care and hospital settings. This study describes a methodology to reduce this effect on glucose analysis using an NIR Fourier transform spectroscopy method combined with a multivariate calibration technique (PLS) using preprocessing by orthogonal signal correction (OSC). A mathematical approach based on the use of a single calibration based bias and slope correction was applied in addition to a standard OSC was investigated. This approach is combined with a factorial interferent calibration design to accommodate for interference effects. We named this approach as a slope and bias OSC (sbOSC). sbOSC differs from OSC in the way it handles the prediction. In sbOSC, statistics on slope and bias obtained from a set of calibration samples are then used as a validation parameter in the prediction set. Healthy human volunteer blood with different glucose (80 to 200 mg/dL) and hematocrit (24 to 48 vol.%) levels containing high expected levels of inteferents have been measured with a transmittance near-infrared Fourier transform spectrometer operates in the broadband spectral range of 1.25-2.5 μm (4000-8000 cm(-1)). The effect of six interferents compounds used in intensive care and operating rooms, namely Dextran, Fructose, Galactose, Maltose, Mannitol, and Xylose, were tested on blood glucose. A maximum interference effect (MIE) parameter was used to rank the significance for the individual interferent type on measurement error relative to the total NIR whole blood glucose measurement error. For comparison, a YSI (Yellow Springs Instrument) laboratory reference glucose analyzer and NIR data were collected at the same time as paired samples. MIE results obtained by sbOSC were compared with several standard spectral preprocessing approaches and show a substantial reduced effect of saccharide interferences. NIR glucose measurement results are substantially improved when comparing standard error of prediction from validation samples; and resulting MIE values are small.     

Quantitative dynamic nuclear polarization‐NMR on blood plasma for assays of drug metabolism

Analytical platforms for the fast detection, identification and quantification of circulating drugs with a narrow therapeutic range are vital in clinical pharmacology. As a result of low drug concentrations, analytical tools need to provide high sensitivity and specificity. Dynamic nuclear polarization‐NMR (DNP‐NMR) in the form of the hyperpolarization–dissolution method should afford the sensitivity and spectral resolution for the direct detection and quantification of numerous isotopically labeled circulating drugs and their metabolites in single liquid‐state NMR transients. This study explores the capability of quantitative in vitro DNP‐NMR to assay drug metabolites in blood plasma. The lower limit of detection for the anti‐epileptic drug ¹³C‐carbamazepine and its pharmacologically active metabolite ¹³C‐carbamazepine‐10,11‐epoxide is 0.08 µg/mL in rabbit blood plasma analyzed by single‐scan ¹³C DNP‐NMR. An internal standard is used for the accurate quantification of drug and metabolite. Comparison of quantitative DNP‐NMR data with an established analytical method (liquid chromatography‐mass spectrometry) yields a Pearson correlation coefficient r of 0.99. Notably, all DNP‐NMR determinations were performed without analyte derivatization or sample purification other than plasma protein precipitation. Quantitative DNP‐NMR is an emerging methodology which requires little sample preparation and yields quantitative data with high sensitivity for therapeutic drug monitoring. Copyright © 2010 John Wiley & Sons, Ltd.     

Design and evaluation of novel blood incubation systems for in vitro hemocompatibility assessment of planar solid surfaces

Success in the development of hemocompatible biomaterials depends on adequate equipment and procedures for standardized analysis of blood-materials interactions in vitro. In view of the limited standard of knowledge on that important aspect, two novel incubation systems were designed, built, and evaluated for the in vitro assessment of the hemocompatibility of planar solid surfaces: A screening setup was introduced for the comparison of up to 12 different samples. A perfusion setup was developed to model the directed blood flow in the vascular system during incubation by a recirculation circuit, allowing the variation of the wall shear rate at the sample surface. The incubation procedures utilized freshly drawn, heparinized whole human blood. Hemocompatibility in terms of selected aspects of coagulation, thrombogenicity, and immune responses was quantified through plasma levels of characteristic molecules (immunoassays), cell counting, and analysis of adherent cells and fibrin formation (scanning electron microscopy), respectively. Prevention of blood-air contact and mechanical stress, constant temperature and blood pH during incubation, and the suitable choice of reference materials were found to be crucial for reliable testing. Considering those requirements, screening and perfusion system both provided sensitive discrimination between a given set of planar solid surfaces. In conclusion, the suggested methods for an in vitro hemocompatibility assessment permit versatile, sensitive, and efficient analysis of important blood-material interactions despite the unavoidable variability of blood characteristics in different experiments.     

Evaluation of a protein microarray method for immuno-typing erythrocytes in whole blood

All donor blood samples must be tested pre-transfusion to determine the blood type of donor erythrocytes, based on the ABO typing system. Current methods of testing are well characterised, but require a number of processing steps prior to analysis. In addition, standard testing protocols require additional assays such as hepatitis C and HIV testing be performed separately. We describe and evaluate a protein microarray platform for ABO blood typing that has the potential to be a simple reliable high throughput method, with the added capability for the integration of other important pre-transfusion tests. Sixty seven donor blood samples were incubated on microarrays printed with multiple spotted replicates of blood type antigen specific antibodies. We utilised a hold-out cross validation approach, combined with Receiver Operator Characteristic (ROC) curves to define thresholds within which a sample could be defined as being of a particular blood type. The threshold values from the ROC curve analysis demonstrated an excellent ability to accurately separate samples based on ABO blood type. The results obtained when the thresholds from the training sets were applied to test sets were also very encouraging, with misclassified samples being present in only 2 of the training sets and a mean classification error of 4.28%. When the mean thresholds were applied to the 67 donor samples, 95.5% were correctly blood typed (64 of 67 samples). We have demonstrated the ability of our protein microarray platform to successfully and accurately type human whole blood samples. We believe that this flexible platform provides a strong basis for an integrated approach for combined blood typing and pathogen testing in human whole blood.     

Cell‐free fetal DNA and fetal blood group genotyping: non‐invasive prenatal testing

In transfusion medicine and clinical immunology, cell‐free fetal DNA (cffDNA) is analysed from maternal plasma of pregnant women to predict fetal blood groups with the purpose of (1) assessing the risk of haemolytic disease of the fetus and newborn (HDFN) in immunized women and (2) guiding targeted Rh prophylaxis in non‐immunized RhD‐negative women. National programmes for guiding prophylaxis are now implemented in around 6–7 European countries; assay accuracy is very high, with sensitivities of 99·9%. Sensitivity is challenged by low quantities of cffDNA, especially in early pregnancy. Specificity is challenged by the polymorphic Rh blood group system, where careful attention is needed to navigate among the many RHD variants that may complicate cffDNA analysis and interpretation of results, especially in populations with mixed ethnicities. However, fetal RHD testing is feasible when implemented with careful attention to these issues. The success of predicting fetal RhD and its successful clinical implementation should encourage widespread implementation. For blood groups that are determined by SNPs, such as KEL or Rhc, novel techniques such as next‐generation sequencing and droplet digital PCR are now providing accurate non‐invasive prediction of these fetal blood groups. Future work on non‐invasive prenatal testing of fetal blood groups determined by SNPs may consolidate the application for cell‐free DNA testing for such targets. At ISBT, the newly formed cfDNA subgroup of the Red Cell Immunogenetics and Blood Group Terminology Working Party will work to facilitate clinical applications, implementation and evaluation of cell‐free DNA testing.     

血液介电参数与血液学指标的相关性分析

利用4294A阻抗分析仪,在频率为0.01~100 MHz范围内测量了30例健康人血液样本的交流阻抗,同时测量了血沉(ESR)、红细胞比容(HCT)、血浆纤维蛋白原(FIB)及血糖(BG)等血液学指标,在获得完整数据的基础上,我们利用线性相关分析方法分析ESR与血液介电参数的相关性;并以多元回归统计学方法分析HCT、BG及FIB对全血细胞介电谱参数的影响。统计学结果显示ESR与部分血液介电参数呈线性相关;HCT和BG对部分血液介电参数有影响,其中HCT是影响血液介电参数最主要的血液学指标。     

European Concerted Action on Anticoagulation (ECAA). An assessment of lyophilised plasmas for ISI calibration of CoaguChek and TAS whole blood prothrombin time monitors

AIMS: The recommended method for the international sensitivity index (ISI) calibration of whole blood point of care testing (POCT) prothrombin time (PT) systems was originally described by Tripodi et al in 1993 but is too complex and demanding. The present European Concerted Action on Anticoagulation (ECAA) study aimed to assess the reliability of simpler ISI calibration using lyophilised plasma samples. METHODS: ISI calibrations using three different types of ECAA lyophilised plasma samples (artificially depleted, individual, and pooled coumarin) were compared with whole blood calibrations on CoaguChek Mini and TAS PT-NC POCT monitors at 10 centres. RESULTS: With CoaguChek Mini systems, lyophilised coumarin plasma samples (both single donation and pooled) gave ISI and international normalised ratio (INR) values comparable to whole blood. With artificially depleted plasma, ISI and INR values were too high. With TAS PT-NC systems, all three types of lyophilised plasma samples gave inaccurate ISI and unreliable INR results, similar to previous ECAA findings with fresh plasma calibrations. CONCLUSIONS: With CoaguChek Mini systems, ISI calibration can be simplified by the use of ECAA lyophilised plasma samples from coumarin treated patients. Further study is needed to devise a simpler calibration method for the TAS PT-NC system.     

European concerted action on anticoagulation. Minimum numbers of lyophilized plasma samples for ISI calibration of CoaguChek and TAS point-of-care whole blood prothrombin time monitors

International sensitivity index (ISI) calibration of whole blood prothrombin time (PT) monitors is too complex. We previously simplified the method by using European Concerted Action on Anticoagulation (ECAA) lyophilized plasma samples with the TAS PT-NC (Bayer AG, Leverkusen, Germany) and the CoaguChek Mini (Roche Diagnostics, Mannheim, Germany) whole blood PT monitoring systems. The TAS PT-NC required a correction derived from the line of equivalence. Monte Carlo bootstrap analysis of reducing numbers of test samples was performed with both systems. Plasma samples from patients receiving coumarin (coumarin samples), healthy subjects (normal samples), and plasma samples artificially depleted of coagulation factors were used. With the TAS PT-NC, 20 coumarin samples or 20 artificially depleted samples with 7 normal samples gave reliable ISI and international normalized ratio and satisfactory precision. With the CoaguChek Mini, 30 coumarin and 10 normal samples were required. Simplification of ISI calibration of the 2 monitoring systems is possible using fewer ECAA lyophilized plasma samples than the 80 required according to the World Health Organization guidelines for conventional PT systems and previously recommended for fresh plasma samples tested on the same 2 monitoring systems.     

Opposite changes in aggregability of platelets stored in plasma and in blood.

The effect of storage on the aggregability of platelets in plasma and in whole blood was studied with blood samples obtained from 11 normal subjects. Compared to aggregation of platelets in fresh samples, those stored in plasma showed an increase in aggregation, and in whole blood a decrease in aggregation. The decreased aggregation in the latter samples was prevented by including exogenous glucose in stored blood samples. Similar studies were performed on 25 patient platelet samples that had been judged as hyperaggregable by standard procedure, including the presence of "spontaneous" aggretation in 13 specimens. Only seven samples prepared from stored blood still showed hyperaggregability; spontaneous aggregation remained in only five samples.     

Minimum numbers of fresh whole blood and plasma samples from patients and healthy subjects for ISI calibration of CoaguChek and RapidPointCoag monitors

The international sensitivity index (ISI) calibration of point-of-care-test (POCT) prothrombin time (PT) whole blood monitors is complex, requiring manual PT testing of 60 patients' and 20 healthy subjects' plasma samples. The possibility of reducing these numbers was studied by a Monte Carlo Bootstrap study for 2 POCT PT systems. For reduced sample numbers, this consisted of 50,000 calibrations using whole blood and plasma samples tested on the monitors with manual PT testing of plasma samples from the same blood donations. There was little effect on mean ISI by reduction of sample numbers to a total of 7, but there was progressively less certainty regarding the reliability of the calibration. Precision of the calibrations and international normalized ratio deviation were not affected markedly by reducing numbers to half As ISI calibration with the 2 POCT systems was less precise than conventional manual testing, for maximum confidence, reduction of numbers is not advised.     

Whole-blood glucose and lactate. Trilayer biosensors, drug interference, metabolism, and practice guidelines

OBJECTIVE: To assess the effects of 30 of the most commonly used critical care drugs on measurements obtained with trilayer electrochemical biosensors on a reference analyzer (ABL625-GL), to determine metabolic changes in glucose and lactate in vitro, and to formulate guidelines for whole-blood analysis of these 2 analytes. DESIGN: Serial measurements were taken of changes in glucose and lactate levels caused by metabolism in whole blood in vitro over time. A parallel control study of drug interference with measurements of glucose and lactate in whole blood and of dose-response relationships in whole-blood samples and in plasma samples also was conducted. RESULTS: At room temperature, whole-blood metabolism decreased glucose levels -2.3% at 15 minutes, -4.6% at 30 minutes, and -6.4% at 45 minutes. Metabolism increased lactate levels 11.4% at 15 minutes, 20.6% at 30 minutes, and 26.7% at 45 minutes in vitro. Paired differences between drug-spiked and control samples were calculated to determine interference (corrected for metabolism). The threshold for determination of interference was +/-2 SD from within-day precision, equal to +/-0.18 and +/-0.10 mmol/L for glucose and lactate, respectively. Only mannitol (C(6)H(14)O(6)) interfered with glucose and lactate measurements. At a concentration of 24 mg/mL, mannitol decreased whole-blood glucose levels by an average of 0.711 mmol/L (12.8 mg/dL) and whole-blood lactate levels by 0.16 mmol/L (1.4 mg/dL). Mannitol interference with measurements may have resulted from suppression of hydrogen peroxide formation in the enzymatic reactions in the biosensors, repartitioning of water between erythrocytes and plasma, or from other mechanisms. CONCLUSIONS: Most critical care drugs had no significant effects on the trilayer electrochemical biosensors. Whole-blood analysis should be performed within 15 minutes for lactate and within 30 minutes for glucose because of metabolism in vitro. Mannitol effects on glucose measurements may be clinically significant in mannitol-induced acute renal failure and therefore should be considered for appropriate diagnosis and treatment of critically ill patients.     

Accuracy of capillary whole blood international normalized ratio on the CoaguChek S, CoaguChek XS, and i-STAT 1 point-of-care analyzers

We evaluated the accuracy of capillary whole blood international normalized ratio (INR) on the CoaguChek S (Roche Diagnostics, Indianapolis, IN), CoaguChek XS (Roche Diagnostics), and i-STAT 1 (i-STAT, East Windsor, NJ) point-of-care (POC) analyzers compared with venous plasma INRs determined by a reference laboratory method. Overall agreement between POC and laboratory plasma INR was very good, with median bias between capillary whole blood and laboratory plasma INRs varying from 0.0 to -0.2 INR units on all devices. More than 90% of results on the CoaguChek XS and i-STAT 1 and 88% of CoaguChek S results were within 0.4 INR units of the reference laboratory method. The CoaguChek XS and i-STAT 1 demonstrated greater accuracy than the CoaguChek S as measured by the number of results that differed by more than 0.5 INR units from the reference method. Median bias between CoaguChek S capillary whole blood and laboratory plasma INRs changed over time, demonstrating the need for ongoing quality assurance measures for POC INR programs.